Evaluating the Emergency Management of Arteriovenous Fistula and Graft Bleeds

Background

Arteriovenous (AV) access bleeding requires prompt management, but little is known about short- and long-term outcomes after these events. Our goal was to evaluate emergency management of AV access bleeds and their outcomes.

Methods

This is a retrospective analysis of emergency department (ED) visits for AV access bleeding at a tertiary care center between 2014 and 2022. Presentation, severity, management, and outcomes were evaluated.

Results

There were 66 patients that met the inclusion criteria (mean age was 65.4 years, 51.5% were male, 66.7% were Black, and 18.2% were Hispanic). Access types included brachiocephalic (34.8%), brachiobasilic (28.8%), radiocephalic (9.1%) fistulas, upper extremity AV grafts (16.7%), and lower extremity access (16.7%). The majority (78.8%) were postcannulation bleeds with 18.2% being primary ulcers. Triage emergency severity index classified ED presentation as life-threatening (6.1%), high-risk (31.8%), urgent (60.6%), and semi-urgent (1.5%). ED interventions included manual pressure (37.9%), suture placement (25.8%), topical hemostatic agents (15.2%), a clamp device (13.6%), and tourniquet placement (1.5%). Vascular surgery was consulted in approximately half (48.5%) of cases. In total, 59% of patients were discharged from the ED and 41% of patients were admitted to the hospital for further management. Tunneled dialysis catheters were placed in 15.2% of all hospitalized patients. In total, 45.5% of patients required an intervention on their access (45.5% open and 54.6% endovascular). In total, 60% and 40% of open operations were access revisions and ligations, respectively. The majority (83.3%) of patients undergoing fistulograms required an intervention. At 90 days, 59% of patients represented to the ED, with 23% of all readmissions for related causes. At 1 year, 22.7% of patients required new AV access creation. Six-month follow-up with an access surgeon was low at only 45.5% of patients. Having an access surgeon evaluate patients in the ED resulted in fewer related readmissions (25% vs. 2.9%, P = 0.02) and 1-year interventions (43.8% vs. 17.7%, P = 0.02), but there was no difference in the need for new AV access creations (12.5% vs. 2.9%, P = 0.19), and the 6-month follow-up in both groups was low (34.4% vs 55.9%, P = 0.08).

Conclusion

Over one-third of AV access bleeds presenting to the ED were of life-threatening or high-risk severity. Many such patients required a new AV access within 1 year. Improved interdepartmental communication and close patient follow-up remain opportunities for improved outcomes.